Anterior Lumbar Interbody Fusion (ALIF) L5-S1 with overpowering of posterior lumbosacral instrumentation and fusion mass: a reliable solution in revision spine surgery.

BACKGROUND AND PURPOSE: In cases of spine surgical revisions of patients affected by sagittal malalignment, the restoration of the ideal lumbar lordosis (LL) is mandatory. ALIF procedures represent a powerful and effective approach to improve the LL in case of hypolordosis. This study evaluates the feasibility of ALIF to overpower posterior lumbar instrumentation and fusion mass in revision spine surgery and secondarily to estimate complications, clinical and radiological outcomes. METHODS: This is a single-center retrospective analysis of prospectively collected data on the use of ALIF overpowering in cases of lumbosacral instrumentation and/or fusion. Demographic, comorbidity, corrective strategy adopted, surgical data, clinical and radiological results, and intraoperative and postoperative complications were recorded. RESULTS: Twelve patients (3 male; 9 female) underwent overpowering ALIF L5-S1 were included in the study with a mean FU of 34.0 ± 13.4 months. In 10 cases, a posterior titanium instrumentation and fusion mass were present; in 2 patients, only a fusion mass was present. Indicators of pain and disability improved in all patients (p < 0.01). Sagittal realignment with the restoration of ideal spinopelvic parameters was obtained in all cases. One peritoneal lesion requiring intraoperative suture without sequelae, two cases of postoperative radiculopathy, and one posterior wound infection requiring surgical debridement and antibiotic therapy were reported. CONCLUSIONS: Anterior implant of lordotic and hyperlordotic cages with increasing segmental lordosis is possible in the presence of posterior instrumentation and/or solid fusion mass. The biomechanical strength of this corrective technique can overcome posterior instrumentation and bone fusion resistance, therefore allowing a single-staged surgery for sagittal realignment.

Revision strategies for failed adult spinal deformity surgery.

PURPOSE: The aim of this study is to analyse the results of revision surgery for failed adult spinal deformity patients and to describe the surgical strategy selection process, based on the identification of the main clinical diagnosis responsible for failure. METHODS: We retrospectively reviewed the clinical and radiological data of 77 consecutive patients treated in a 3-year time (2016-2019) for surgical revision of long fusion (more than five levels fused) for adult spinal deformity in a high-volume spine centre, divided into four groups based on the diagnosis: rod breakage (RB) group, proximal junctional failure (PJF) group, distal junctional failure (DJF) group and loss of correction (LOC) group with symptomatic sagittal or coronal malalignment (including iatrogenic flatback). RESULTS: Seventy-seven patients met our inclusion criteria, with a female prevalence (66 F vs. 11 M). The mean age at revision surgery was 63. Fused levels before surgery were averagely 12, and revision added averagely two levels to the preexisting fusion area. Clinical status was apparently improved in ODI scores and VAS scores, while it was slightly worsened in SF36 scores. Different diagnosis groups have been addressed with different surgical strategies, according to the different surgical goals: interbody cages and multi-rod construct to improve stiffness and favour bony fusion, "kickstand" rod and "tie" rod to correct coronal and sagittal malalignment, specific rod contouring and proximal hooks in "claw" configuration to reduce mechanical stress at the proximal junctional area. Intraoperative complications occurred in 18% of patients and perioperative complications in 39%. CONCLUSION: Revision surgery in long fusions for adult spinal deformity is a challenging field. Surgical strategy should always be planned carefully. A successful treatment is a direct consequence of a correct preoperative diagnosis, and surgery should address the primary cause of failure. All the above-mentioned surgical techniques and clinical skills should be part of surgeon's expertise when managing these patients. These slides can be retrieved under Electronic Supplementary Material.

Effects of magnetically controlled growing rods surgery on pulmonary function in young subjects with spinal muscular atrophy type 2 and other neuromuscular scoliosis.

BACKGROUND: The aim of this study was to determine the effects of magnetically controlled growing rods surgery (MCGRS) of the scoliosis on pulmonary function in children with neuromuscular scoliosis. METHODS: Seven patients, 85.7% female (mean±SD age: 6.7±1.2 years), with neuromuscular scoliosis (4 SMA II, 2 congenital myopathies and 1 VACTER syndrome), received MCGRS of the spine in the thoraco-lumbar area. The outcome measures were clinical features and pulmonary function (forced vital capacity [FVC] and forced expiratory volume in 1st second [FEV1], were collected. All measures were collected at pre-, post-intervention and follow-up (short-term [0-6 months], mid-term [7-12 months], and long-term [13-24 months]). RESULTS: MCGRS reduced Cobb angle after intervention in 100% in subjects and this result was maintained at 24-month follow-up (all, P=0.001). There was no significant difference in FVC or FEV1 between preoperative and each postoperative period, (P>0.05). Analyses of the correlation coefficients indicated no significant associations between changes in pulmonary function and scoliosis. CONCLUSIONS: The current study found that MCGRS addressed to the scoliosis maintained pulmonary function during long-term follow-up; However, pulmonary function was not associated with scoiosis in children with neuromuscular scoliosis.

C1-C2 arthrodesis after spontaneous Propionibacterium acnes spondylodiscitis: Case report and literature analysis.

BACKGROUND: Propionibacterium acnes (P. acnes) is a microaerophilic anaerobic Gram-positive rod responsible for acne vulgaris. Although it is often considered to be a skin contaminant, it may act as a virulent agent in implant-associated infections. Conversely, spontaneous infectious processes have been rarely described. CASE DESCRIPTION: Here, we describe a 43-year-old female with C1-C2 spondylodiscitis attributed to P. acnes infection. Despite long-term antibiotic treatment, computed tomography demonstrated erosion of the C1 and C2 vertebral complex that later warranted a fusion. One year postoperatively, the patient was asymptomatic. CONCLUSIONS: Clinical knowledge of P. acnes virulence in spontaneous cervical spondylodiscitis allows early diagnosis, which is necessary to prevent or reduce complications such as cervical deformity with myelopathy or mediastinitis.

Surgical treatment of spinal disorders in Parkinson's disease.

PURPOSE: Most patients suffering from Parkinson's disease (PD) exhibit alterations in the posture, which can in several cases give rise to spine deformities, both in the sagittal and the coronal plane. In addition, degenerative disorders of the spine frequently associated to PD, such as spinal stenosis and sagittal instability, can further impact the quality of life of the patient. In recent years, spine surgery has been increasingly performed, with mixed results. The aim of this narrative review is to analyze the spinal disorders associated to PD, and the current evidence about their surgical treatment. METHODS: Narrative review. RESULTS: Camptocormia, i.e., a pronounced flexible forward bending of the trunk with 7% prevalence, is the most reported sagittal disorder of the spine. Pisa syndrome and scoliosis are both common and frequently associated. Disorders to the spinopelvic alignment were not widely investigated, but a tendency toward a lower ability of PD patients to compensate the sagittal malalignment with respect to non-PD elderly subjects with imbalance seems to emerge. Spine surgery in PD patients showed high rates of complications and re-operations. CONCLUSIONS: Disorders of the posture and spinal alignment, both in the sagittal and in the coronal planes, are common in PD patients, and have a major impact on the quality of life. Outcomes of spine surgery are generally not satisfactory, likely mostly due to muscle dystonia and poor bone quality. Knowledge in this field needs to be consolidated by further clinical and basic science studies. These slides can be retrieved under Electronic Supplementary Material.

Spinopelvic parameter changes and low back pain improvement due to femoral neck anteversion in patients with severe unilateral primary hip osteoarthritis undergoing total hip replacement.

PURPOSE: The study of the interrelation between hip and spine disorders is gaining increasing importance in the last years, but the link between Hip Osteoarthritis (HOA) and Low Back Pain (LBP) remains still unclear. Aim of the study is to assess the relationship between Femoral Neck Anteversion (FNA), LBP, and spinopelvic parameters in patients undergoing Total Hip Replacement (THR) for unilateral severe primary HOA. MATERIALS AND METHODS: 91 patients were recruited. Inclusion criteria were: grade 5 or 6 unilateral HOA, according to Turmezei, and Harris Hip score (HHS) <60. Exclusion criteria were: secondary hip osteoarthritis (dysplasia of the hip, rheumatoid arthritis, and ankylosing spondylitis); previous surgery of the spine, hip or knee; scoliosis with a Cobb angle greater than 10°; spondylolisthesis; history of spine fractures; previous bone tuberculosis or any spine infections; any contraindications to CT; BMI >30. Patients were divided into two homogeneous Groups according to the presence (Group-A) or not of concomitant LBP (Group-B). All patients underwent preoperatively a hip CT scan to evaluate FNA, Acetabular Anteversion (AA), and Combined Anteversion (CA = FNA + AA). ΔFNA, ΔAA and ΔCA were calculated as the differences between the arthritic hip and the normal hip angles in each Group. Full spinal X-rays in upstanding position were performed before (baseline) and 6 months after THR (follow-up) to calculate spinopelvic parameters. The health-related quality of life (HRQoL) was evaluated at baseline and at follow-up using Visual Analogue Scale (VAS), HHS, Oswestry Disability Index (ODI), Roland-Morris Disability Questionnaire (RM), and Short-Form Health Survey (SF-36). The intra-group and inter-group variability were assessed using, respectively, paired and unpaired t tests. At baseline, the association between HRQoL scores and ΔFNA, ΔAA, and ΔCA was analysed by the Pearson correlation test. RESULTS: At baseline, in Group-A, there was a significant difference between arthritic FNA and normal hip FNA, while no differences were found in AA between the two hips. A close correlation was observed between ΔFNA and Spine-VAS (r = 0.788), ODI (r = 0.824), and RM (r = 0.775). In Group-B, there was not a significant difference in FNA and AA between the two hips. At recruitment, in Group-A patients, we recorded a higher LL, SS, PI, SVA(C7), and a lower PT and T1-SPI compared with Group-B subjects. Six months after THR, in Group-A, an improvement of all clinical scores was recorded, as well as, a significant reduction of SS, LL, T1PA, and SVA(C7) and an increment of PT. In Group-B, at follow-up, an improvement of HHS, Hip-VAS, and SF-36 was recorded, while the changes in spinopelvic parameters were not significant. CONCLUSIONS: Patients with concomitant unilateral HOA and LBP showed a marked anteverted FNA in the arthritic hip and a spinopelvic misalignment. After THR, a relief of both hip and low back pain and a change in spinopelvic parameters is observed.

Long fusions to S1 with or without pelvic fixation can induce relevant acute variations in pelvic incidence: a retrospective cohort study of adult spine deformity surgery.

PURPOSE: The purpose of this study is to verify if any changes occur in pelvic incidence (PI) in adult patients undergoing long fusion to sacrum for spine deformity and to describe the effect of fixation to pelvis on these variations. METHODS: We conducted a cross sectional study. Sixty-six adults patients, 87% females (mean ± SD age: 65.1 ± 7.6 years), undergoing fusion from the thoracic spine to the sacrum for adult spine deformity were included. Patients were divided in two different groups: Group A: sacral fixation alone and Group B: sacral fixation plus pelvis fixation. Pre and postoperative standardized full-standing X-rays were analyzed with measurement of: PI, pelvic tilt (PT), lumbar lordosis (LL) and sagittal vertical axis (SVA). RESULTS: A significant effect of time interaction (preoperative to early postoperative; F = 59.93, F = 44.78 and F = 39.87, all p < 0.001) existed for PT, SS and TK in both groups (all, p < 0.001). After adjustment for patients' age (>65 vs. <65 years), a statistically significant increase of PI was observed in patients >65 years (p = 0.006) in Group A between preoperative and postoperative measurements. All patients in Group B exhibited a decrease in PI from preoperative to postoperative. CONCLUSIONS: Older patients undergoing long fusion to the sacrum without pelvic fixation had an increase in PI after surgery. Conversely, pelvic fixation with hips intraoperatively extended has decreased the value of PI from pre- to early postoperative. These changes could be related to degeneration of the sacroiliac joints causing increased rotational mobility and the magnitude of the differences is in the range of clinical relevance.

Anterior cervical corpectomy for cervical spondylotic myelopathy: Reconstruction with expandable cylindrical cage versus iliac crest autograft. A retrospective study.

OBJECTIVES: To compare retrospectively the clinical and radiographic outcomes between cervical reconstruction with expandable cylindrical cage (ECC) and iliac crest autograft after one- or two-level anterior cervical corpectomy for spondylotic myelopathy. PATIENTS AND METHODS: Forty-two patients underwent cervical reconstruction with either iliac crest autograft and plating (20 patients) or ECC and plating (22 patients). The average clinical and radiological follow-up period was 77.54 ± 44.28 months (range 14-155 months). The authors compared clinical parameters (Nurick Myelopathy Grade, modified Japanese Orthopedic Association (mJOA) scores), perioperative parameters (hospital stays, complications) and radiological parameters (Cobb's angles of the fused segments and C2-C7 segments, cervical subsidence, fusion rate). Fusion was assessed on flexion-extension X-ray films. RESULTS: No significant differences between the two groups were found in demographics, neurological presentation, preoperative sagittal alignment, clinical improvement and length of hospitalization. Patients of the autograft group experienced more postoperative complications, although the difference between the two treatment groups was not statistically significant (15 versus 4.5%, p=0.232). The fusion rate was 100% in both groups. The average lordotic increase of the segmental angle was significantly greater in the ECC group (p<0.05). Other radiological parameters were not significantly different in the two groups. CONCLUSION: Cervical reconstruction either with iliac crest autograft and plating or ECC and plating provides good clinical results and similar fusion rates after one- or two-level corpectomy for spondylotic myelopathy. However, the use of ECC obviates donor site complications and provides a more significant increase of lordosis in segmental angle.

Anterior column realignment from a lateral approach for the treatment of severe sagittal imbalance: a retrospective radiographic study.

INTRODUCTION: Adult deformity combined with sagittal malalignment is a pathology that decreases patient's quality of life and that requires surgical correction to achieve clinical improvement. Spine osteotomies are usually performed to restore alignment of the spine, even if these techniques are associated with high intraoperative risks, revision rates and relevant mortality rates. Anterior column realignment (ACR) is a new technique that allows large corrections through a minimally invasive lateral approach to the spine after release of the anterior longitudinal ligament. MATERIALS AND METHODS: Preoperative and postoperative full-standing X-rays of 12 patients who underwent ACR procedure were retrospectively reviewed. Spinopelvic alignment parameters of sagittal balance were measured on standing full-spine radiographs. Any intraoperative or postoperative complication was reported, as technical notes such the number of treated levels, associated XLIFs and cases of revision surgery. RESULTS: 11 out of 12 patients had a complete data set and were enrolled in this study. The mean preoperative and postoperative lumbar lordosis values were, respectively, -20° ± 17° and -51° ± 9.8° (p < 0.001), while a mean value of 27° of lordosis were restored at a single ACR level. Two major complications occurred, a bowel perforation and a postoperative early infection of the posterior wound that required surgical debridement. CONCLUSIONS: Preliminary data show that ACR allows corrections similar to those obtained with a Pedicle Subtraction Osteotomy, avoiding risks related to this technique.